Concordant and Discordant Exudates and Their Effect on the Accuracy of Light’s Criteria to Diagnose Exudative Pleural Effusions

Ferreiro, Lucía; Sánchez-Sánchez, Rolando; Valdés, Luís; Kummerfeldt, Carlos E.; Huggins, John T.

doi:10.1016/j.amjms.2016.08.016

Cited by 13 publications

(8 citation statements)

References 20 publications

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“…Differential diagnoses of TMPEs include TPEs, malignant pleural effusions, parapneumonic pleural effusion, pleural effusion caused by connective tissue disease, and other viral infections [8][9][10]. The clinical manifestations (fever, anemia, debilitation, and athrepsia, often accompanied by cough, chest pain, enlarged lymph nodes, and tuberculosis-like pathogenesis); imaging examination findings (patchy infiltrates, extensive consolidation, fibroelastosis, cavity, and pleural effusion); and histopathology (micro-abscess or granulomas) of TMPEs are similar to those of tuberculosis [5,6,11].…”

Section: Discussionmentioning

confidence: 99%

“…Corresponding samples of TMPE and TPE obtained by thoracentesis under sterile conditions, were retrieved from a pleural bank maintained in our laboratory (stored at − 80°C). Exudates were characterized using Light's criteria [9,10].…”

Section: Study Design Participants and Pleural Fluid Samplesmentioning

confidence: 99%

“…Talaromycosis were diagnosed based on positive cultures for T. marneffei, characterized by dimorphic fungi that grew as a mold at 25°C, and as yeast at 37°C from clinical specimens [1][2][3][4] (e.g., pleural effusion, pleura, blood, bone marrow, lymph nodes, sputum, skin scrapings, or bronchoalveolar lavage fluid [BALF]). Alternatively, it was diagnosed when the yeast form of T. marneffei was confirmed by cytology and histopathology (from tissues and secretions using Periodic Acid-Schiff [PAS] staining or Wright's-stain), showing a characteristic morphology that includes a transverse septum [7][8][9][10]. Disseminated disease was defined as infection in at least two noncontiguous and sterile sites.…”

Section: Diagnostic Criteria For Talaromycosismentioning

confidence: 99%

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Comparison of pleural effusion features and biomarkers between talaromycosis and tuberculosis in non-human immunodeficiency virus-infected patients

et al. 2019

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Background: Due to the similar clinical, lung imaging, and pathological characteristics, talaromycosis is most commonly misdiagnosed as tuberculosis. This study aimed to identify the characteristics of talaromycosis pleural effusion (TMPE) and to distinguish TMPE from tuberculosis pleural effusion (TPE). Methods: We enrolled 19 cases each of TMPE and TPE from Guangxi, China. Patients' clinical records, pleural effusion tests, biomarker test results, and receiver operating characteristic curves were analyzed. Results: In total, 39.8% (65/163) of patients exhibited serous effusion, of whom 61 were non-human immunodeficiency virus (HIV)-infected patients; 68.85% of the non-HIV-infected patients (42/61) had TMPE. Thoracentesis was performed only in 19 patients, all of whom were misdiagnosed with tuberculosis and received long-term anti-tuberculosis treatment. In four of these patients, interleukin (IL)-23, IL-27, and interferon-gamma (IFN-γ) measurements were not performed since pleural effusion samples could not be collected because the effusion had been drained prior to the study. In the remaining 15 patients, pleural effusion samples were collected. Talaromyces marneffei was isolated from the pleural effusion and pleural nodules. Most TMPEs were characterized by yellowish fluid, with marked elevation of protein content and nucleated cell counts. However, neutrophils were predominantly found in TMPEs, and lymphocytes were predominantly found in TPEs (both p < 0.05). Adenosine deaminase (ADA) and IFN-γ levels in TMPEs were significantly lower than those in TPEs (all p < 0.05) and provided similar accuracies for distinguishing TMPEs from TPEs. IL-23 concentration in TMPEs was significantly higher than that in TPEs (p < 0.05), and it provided similar accuracy for diagnosing TMPEs. IL-27 concentrations in TMPEs were significantly lower than those in TPEs (all p < 0.05) but was not useful for distinguishing TMPE from TPE. Conclusions: Talaromycosis can infringe on the pleural cavity via the translocation of T. marneffei into the pleural space. Nonetheless, this phenomenon is still commonly neglected by clinicians. TMPE is a yellowish fluid with exudative PEs and predominant neutrophils. Higher neutrophil counts and IL-23 may suggest talaromycosis. Higher lymphocyte counts, ADA activity, and IFN-γ concentration may suggest tuberculosis.

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Section: Discussionmentioning

confidence: 99%

Section: Study Design Participants and Pleural Fluid Samplesmentioning

confidence: 99%

Section: Diagnostic Criteria For Talaromycosismentioning

confidence: 99%

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Comparison of pleural effusion features and biomarkers between talaromycosis and tuberculosis in non-human immunodeficiency virus-infected patients

et al. 2019

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“…Both criteria needed to be present in order to classify the effusion as an exudate. If only one of these criteria was met, the effusion was considered to have discordant biochemistry [3], to differentiate from exudates (meeting both criteria).…”

Section: Methodsmentioning

confidence: 99%

Prospective Analysis of the Predictive Value of Sonographic Pleural Fluid Echogenicity for the Diagnosis of Exudative Effusion

et al. 2019

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Background: Pleural effusion echogenicity on ultrasound has previously been suggested to allow identification of exudates. A case series suggested that homogenously echogenic effusions are always exudates. With modern imaging techniques and more advanced ultrasound technology, this may no longer be true. Objectives: This study aims to prospectively assess the predictive value of echogenicity in the identification of exudates. Method: Patients undergoing thoracic ultrasound before pleural fluid sampling were analysed prospectively (n = 140). Pleural fluid was classified as an exudate if both fluid total protein (TP) > 29 g/L and fluid lactate dehydrogenase (LDH) > 2/3 upper limit of normal serum LDH (which is 255 IU/L in females and 235 IU/L in males) were present. If only one of these criteria was met, the effusion was considered to have discordant biochemistry. Results: Fifty-five (39%) patients had non-echogenic and 85 (61%) had echogenic effusions. Six (7.1%) patients with echogenic effusions had transudates; the median fluid TP for this group was 18.5 g/L (IQR 9.75) and median LDH 63.0 IU/L (IQR 40.3). The specificity of echogenicity identifying exudates from transudates, excluding patients with discordant biochemistry, was 57.1%, positive predictive value (PPV) 90.3%, sensitivity 65.1%, and negative predictive value (NPV) 21.0%. The specificity of echogenicity identifying exudates (including discordant biochemistry) from transudates was 57.1%, PPV 92.9%, sensitivity 62.7%, and NPV 14.5%. Conclusions: Echogenicity of a pleural effusion has a low specificity for identifying an underlying exudate, and the echogenic qualities of the fluid should not influence clinical decision-making.

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“…Light's criteria (5) is currently the gold standard method for differentiating effusion types and is used for both pericardial and pleural fluid evaluation, although only validated for pleural effusions (6). Misclassification is common (7,8) with 15-30% of transudates misclassified as exudates (9), resulting in additional unnecessary investigations and delays to appropriate treatment.…”

Section: Introductionmentioning

confidence: 99%

Non-invasive characterization of pleural and pericardial effusions using T1 mapping by magnetic resonance imaging

Rosmini

Seraphim

Knott

et al. 2021

European Heart Journal - Cardiovascular Imaging

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Aims Differentiating exudative from transudative effusions is clinically important and is currently performed via biochemical analysis of invasively obtained samples using Light’s criteria. Diagnostic performance is however limited. Biochemical composition can be measured with T1 mapping using cardiovascular magnetic resonance (CMR) and hence may offer diagnostic utility for assessment of effusions. Methods and results A phantom consisting of serially diluted human albumin solutions (25–200 g/L) was constructed and scanned at 1.5 T to derive the relationship between fluid T1 values and fluid albumin concentration. Native T1 values of pleural and pericardial effusions from 86 patients undergoing clinical CMR studies retrospectively analysed at four tertiary centres. Effusions were classified using Light’s criteria where biochemical data was available (n = 55) or clinically in decompensated heart failure patients with presumed transudative effusions (n = 31). Fluid T1 and protein values were inversely correlated both in the phantom (r = −0.992) and clinical samples (r = −0.663, P < 0.0001). T1 values were lower in exudative compared to transudative pleural (3252 ± 207 ms vs. 3596 ± 213 ms, P < 0.0001) and pericardial (2749 ± 373 ms vs. 3337 ± 245 ms, P < 0.0001) effusions. The diagnostic accuracy of T1 mapping for detecting transudates was very good for pleural and excellent for pericardial effusions, respectively [area under the curve 0.88, (95% CI 0.764–0.996), P = 0.001, 79% sensitivity, 89% specificity, and 0.93, (95% CI 0.855–1.000), P < 0.0001, 95% sensitivity; 81% specificity]. Conclusion Native T1 values of effusions measured using CMR correlate well with protein concentrations and may be helpful for discriminating between transudates and exudates. This may help focus the requirement for invasive diagnostic sampling, avoiding unnecessary intervention in patients with unequivocal transudative effusions.

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Concordant and Discordant Exudates and Their Effect on the Accuracy of Light’s Criteria to Diagnose Exudative Pleural Effusions

Cited by 13 publications

References 20 publications

Comparison of pleural effusion features and biomarkers between talaromycosis and tuberculosis in non-human immunodeficiency virus-infected patients

Comparison of pleural effusion features and biomarkers between talaromycosis and tuberculosis in non-human immunodeficiency virus-infected patients

Prospective Analysis of the Predictive Value of Sonographic Pleural Fluid Echogenicity for the Diagnosis of Exudative Effusion

Non-invasive characterization of pleural and pericardial effusions using T1 mapping by magnetic resonance imaging

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